Welcome! Blood, guts, trauma, surgery, and life saving intervention keep us on the adrenaline roller coaster of the ER. Of course, it's not always positive. The ER can be an emotionally taxing and sometimes heartbreaking workplace, and this blog serves as an outlet for the stress of making life and death decisions each and every day.

Friday, June 24, 2011

Last night, a 2 year old poodle was rushed into the hospital. The client reported that "Peanut" was out on a walk, limped for only two steps, and then collapsed. Peanut was limp, not responsive, and her client was understandably hysterical.

On physical exam, Peanut's situation was grim. She was comatose and therefore, not responsive to external stimuli. She was unable to move any part of her body; her heart rate was extremely low and her breaths were shallow and slow. Her mucous membranes were gray, with a pallor that is usually only seen on a deceased patient.

We jumped in to action. The most likely explanation for a sudden collapse in a young dog was anaphylaxis, in our area, most likely from a bee sting or insect bite.

An IV catheter was placed; I started to bolus IV fluids in attempt to restore circulation; oxygen was provided. We administered epinephrine to halt the reaction as well as improve the heart rate and blood pressure, a steroid to combat the immune response, as well as benadryl and GI protectant medications. Over about 40 minutes, Peanut steadily improved to sit up. When another client came to the front door, she surprised us all and started to bark! It was an amazing change, and she was on the right track.

Over the evening, Peanut improved steadily, and was remarkably eating and drinking within 4 hours.

Despite the overwhelming positive progress, one single concern emerged. Peanut was oozing blood from any place on her body where blood had been taken, despite adequate pressure wraps. Clotting times were evaluated, and Peanut was suffering from a coagulopathy secondary to her near-death experience. Fortunately, her owner allowed a plasma transfusion, and 3 hours later, Peanut appeared as normal as ever. Her mom came to pick her up this morning, and Peanut jumped, squealed and wagged her tail in joy of seeing her. The client was equally as happy; she thanked us for saving her precious dogs' life.

Tuesday, June 21, 2011

The busy weekend continued with evaluation of "Gus," a 4 year old labrador, who had been vomiting and not eating for 3 days. He was a typical lab, with a habit of eating anything not nailed down. He had been hospitalized for 24 hours, and was not improving; he had continued to vomit despite lack of food offered to him. Radiographs from the previous day were suspicious, but not diagnostic for an obstruction.

I assessed Gus, and took him to the ultrasound for further investigation of his abdomen. Ultrasound was overwhelmingly abnormal. His loops of intestine were dilated with fluid, and sharp turns were noted, indicating a possible obstruction. The actual item could not be visualized, but based on these findings, I recommended surgical exploratory.

His electrolytes were performed, and revealed a hypokalemic, hypochloremic metabolic alkalosis; classic for upper GI obstruction, (but also can occur in patients with frequent vomiting).

In Gus' case, the suspicion for a foreign object being lodged in his intestines was increased by his breed, his age, his history and lack of improvement despite therapy, as wells asthe results of radgiographs and ultrasound. Surgical exploratory was the only way to be sure of the cause of Gus' illness, but in his case (and most others), there is always a risk of performing surgery, only to find nothing. No obstruction, no foreign object, and no macroscopic reason for the pet's illness. This is unbelievably frustrating for the client, given the expense of surgery, as well as the pain and recovery time associated with it. It is also unbelievably frustrating for the veterinarian, who obviously wishes to perform surgery on all the right animals, and not perform surgery on those who don't need it. On the other hand, the risk of NOT performing surgery on an animal with a GI obstruction is extreme; if the object remains lodged in the intestines, in can result in damage to the intestines, requiring portions to be removed, or in the most severe case,can cause rupture of the GI tract, and an overall much worse prognosis for recovery (or even death).

With these facts in mind, I discussed the recommendations' to Gus' family. Surgical exploratory did have the small risk of anestheia, as well as the cost and associated healing time, however doing nothing could potentially result in significant worsening of his condition. They wished to proceed with surgery, and so Gus was prepped for his surgical procedure.

Anesthesia was uneventful, and Gus' vitals all remained normal throught the procedure. What I found at surgery, however, was just the frustrating finding I had hoped not to see; no foreign object, a negative explore. Gus' stomach was filled with fluid, his intestines were dilated and had no normal movement, but there was no clear macroscopic reason for his illness.

Frustration washed over me as I evaluated the entire length of his GI tract again, just to be sure. Nothing. No rock, sock, string, or nylons to take out, and no clear reason why Gus had been feeling sick for three days. The adage you learn in veterinary school is, "If you aren't doing any negative abdominal exploratories, then you aren't doing enough abdominal explores." This comment, while true, is not comforting when you're staring into a dog's abdomen, wondering why you cut him open.......

The meaning of this comment is based in statistics. I'll refrain from boring you with the mathematical details, but in summary: The goal is to never miss a true foreign body (FB), so as to avoid harming the patient (or having one die). As every patient with a FB can look different, some patients without a FB will mimic those who have a true obstruction. Essentially, surgical exploratory is called an "exploratory" because, in the right situation, it is not only a therapeutic procedure, but also a diagnostic one. As nobody can be 100% correct every single time, it's better to have a few "negative" explores, than a few patients with an obstruction who are missed, and subsequently die.

Often, patients without foreign objects who undergo surgery do very well afterwards; it's been jokingly referred to as a "therapeutic gut stir" or "letting out the evil vapors." The pain of surgery typically abates in <24 hours, and they return to happy, healthy lives with their families. As frustrating as a negative explore can be, I'd take one every time over a dog who didn't have surgery soon enough. It's a delicate balance and a difficult decision each and every time.

Anyway, I digress. I biopsied Gus' intestines, in hopes of determining the cause of his GI illness, and he recovered uneventfully. He discharged the next day, eating, no longer vomiting and back to his normal self.

Monday, June 13, 2011

I arrived to work on Saturday in a great mood - ready for the day, and hopeful for a busy and rewarding shift. Sometimes, I should be careful what I ask for!

Saturday started out with very few patients already admitted to the hospital. Before I even had the chance to evaluate these patients, client after client started to arrive at the front door en masse. Within the first hour, there were 5 patients waiting to be seen, with more on the way.

"Leo," a 18 year old gray tabby cat, presented for bleeding from his mouth. He had otherwise been a previously very healthy cat. Leo was indoors only, so trauma was very unlikely. As I to take a detailed history from his concerned owner, I began my full nose-to-tail physical exam. My standard physical exam is performed the same way every time, in the effort to be the most efficient and to avoid forgetting any sections of the body. I start at the patient's head, with ears, eyes, nose, throat first, then moving to an oral exam, followed by listening to the heart and lung sounds, palpating the abdomen, and finally evaluating the extremities, performing a neurologic exam, and a rectal exam.

Leo's diagnosis was visible before I even left the first segment of his exam. An expansile, large fleshy mass was present at the base of his tongue, and clotted blood was present where he had likely bit the tumor, resulting in the symptoms noted by the owner. Unfortunately, given the size and location of this mass, Leo's options would be limited, and the client instantly knew this when I gave him the sad news.

A 2 year old dog had arrived and was brought in on a stretcher. The 160lb Rottweiler was stumbling, and acting bizzare, according to the owners. Immediately on examination of "Gus," his diagnosis was unmistakable. Gus was headshy, and when left alone, would fall alseep. He could walk, but had a drunken, ataxic gait. He was dribbling urine - all hallmark signs of marijuana toxicity. His clients, with red, bloodshot eyes, wearing Bob Marley apparel (I'm not exaggerating!), and smelling of Mary Jane, claimed that it was completely impossible for Gus to have had access to pot. "No way, man," they claimed.

Sure.

I tried to explain to them that my only interest is in the health of their pet, and if there really was no access to THC, then we needed to be aggressive about determining the actual toxin or process responsible for Gus' symptoms. I offered drug testing, antifreeze testing, and a biochemical panel to evaluate internal organ function. After reviewing costs, the clients declined testing, and requested treatment for THC.

The next patient to require my attention was a 5 year old orange tabby who had just been closed in a garage door. Fortunately, the friendly, fat kitty had only suffered some minor brusing and soft tissue injury of his pelvic region, and radiographs ruled out pelvic fractures. He'd be back to chasing mice in no time.

I had a very busy weekend in the ER, complete with trauma, run of-the-mill bite wounds, lacerations, and plenty of vomiting and diarrhea.

The best save of the weekend was a 4 month old, adorable pit-bull puppy who had just been hit by a car. On presentation, her mucous membranes were gray and muddy, and a capillary refill time was not detectable (as in, the color never returned as it was incredibly poor to start). Her pulses were poor, and she was having difficulty breathing. Lung sounds were ausculted over her entire chest, but crackles were noted, likely due to bruising.

We immediately provided her with oxygen, placed an IV catheter, and started bloodwork. She began to breathe easier, but her blood pressure was 58mmHg. Way too low (normal systolic being at least 90-100mmHg). At a BP of <60, vital organs were being starved of oxygen, and the longer she spent at this level of hypotension, the more likelihood of irreparable damage. We had to act fast.

Her owners, a very nice young couple, authorized any and all care provided. The young man, probably in his early 20's, begged me to save his dog. He had just lost his sister at a young and unexpected age, and couldn't bear to lose his best friend, "Lucy." He requested the best care we could provide, regardless of the cost, including CPR, surgery, or anything else that would potentially become necessary. "Save my dog!" He cried. "Please! You have to save my dog!" I assured him that we would do everything in our power, but sometimes, we lose them anyway. Unfortunately, there's no guarantee in medicine, but I'd do my absolute best (as I always try to do).

We started with crystalloid fluid boluses, careful to mind her injured lungs, however at this point, hypotension was her primary danger. Her BP improved to 70 after two boluses, but this was still unacceptable for her organ function. I moved to a hetastarch bolus (a colloid fluid, which remains within the vessels longer and can provide additional BP support), which bumped the BP up to 80, and then finally, after ~45 minutes of fluid resuscitation, her BP was 110 mmHg.

Chest radiographs revealed significant intrathoracic trauma; a mild amount of free air which had escaped from her damaged lung (this is called a pneumothorax), contusions and collapse of about 1/4 of her lung lobes. The amount of air in her chest was not a sufficient volume to require thoracocentesis, as long as this air did not continue to accumulate, it would resolve with time and supportive care. Also, her diaphragm appeared to be ruptured, with a portion of her liver moving into her chest. Fortunately, no orthopedic injuries (fractures or luxations) were noted, and her urinary bladder, gall bladder and GI appeared intact. Only a scant amount of fluid was present within her abdomen (likely a mild amount of bleeding from blunt trauma, and very common with this type of injury).

The puppy was on the road to recovery. She spent the evening with the overnight veterinarian, who would provide the same expert level of care. If she became unable to breathe, emergency surgery might become necessary to repair her diaphragm. Lucy was still at risk of declining in the over night period -- I had difficulty sleeping when I arrived home, anxious to find out how my little Lucy's night would turn out.

When I returned to work the next day, I was happy to see Lucy off of oxygen. She was breathing well on room air, no longer requiring the additional supplementation of bottled oxygen. Over the course of the day, she became playful, ate vigorously, and started to act like a real puppy again. In even better news, a recheck of her radiographs revealed that the previous collapsed lung and bruising was already on the mend, and her diaphragm may not require surgery!

"Lucy" went home to her family the following day, almost as good as new. They plan to recheck the radiographs in several days to determine if a true rupture of her diaphgram is present, or if the radiographic changes were due to thoracic trauma alone.

I'm proud of this save, I'm happy that despite the severity of Lucy's injuries and her near-death experience, we were able to return her home to her family, and that for this young man, the trip to my ER was a happy one.

Saturday, June 11, 2011

"Greg," a 40 something, normal-enough looking man, brought in his 10 month old yellow lab, "Jesse" for vomiting of 2 days duration. Jesse was not eating for 2 days, and had not produced any feces. She was known for eating objects, and yesterday had vomited up football leather and some ceramic pieces.

Her abdomen was painful, she was dehydrated, lethargic, and clearly nauseated. I recommended radiographs, and Greg agreed. Her history and exam were extremely consistent with foreign body/GI obstruction, and likely, she would require exploratory surgery. Unfortunately, Greg informed me that surgery was off the table. Initially I understood his position; exploratory surgery is expensive, and perhaps Jesse would not have an GI obstruction. If she was obstructed, surely he would change his mind. Right?

Wrong.

Jesse's radiographs were clearly obstructive; there was nothing equivocal about them. A large, jagged rock was present in the duodenum; the stomach was dilated with fluid and the remainder of the intestines appeared dilated and plicated. Surgery was clearly indicated, and the sooner, the better.

Greg coldly declared that there was no way he was going to spend the money on "this damn dog." I offered him Care Credit, our financing plan -- but he declined. Greg informed me that he already had the finances available, but had no interest in spending money on fixing his dog. "She'll just do it again, and I don't want to pay for her surgery if she's just going to eat something else."

I was taken aback by his cold, uncaring attitude. I offered him an attempt at medical management, or to contact other veterinarians in town (including his primary care veterinarian) to determine if costs might be cheaper and within his range.

"Absolutely not" Greg said. "I'll take him out back, and .... well, you know. I'll take care of it."

I've heard this before, and I wasn't surprised by a client hinting at shooting their own dog, but I still don't condone it. I expressed my concerns for this choice, however he was unwilling to change his mind.

I then offered to give his dog some pain medications in preparation for his plan to take her home. He refused. This is when I became infuriated -- an injection of a pain reliever is less than $30, and would provide his pet with some comfort in her last few hours. He declined not out of concern for finances - he explained explicitly -- but because he just didn't care.

Awful. Awful, horrible, terrible, no good human being.

Eventually, his wife convinced him to allow euthanasia. Thank goodness for her - I was able to let Jesse pass peacefully. As much as I wish I would have been able to fix her, I'm honestly thankful that this monster of a human didn't take her home.

"Roscoe", a 14 year old Akita mix, presented with a sudden onset of panting. Roscoe's very attentive, loving family reported that he had been compeltely normal in the previous days and weeks; today he was suddenly different. Unwilling to rise, panting, and they just felt that he was uncomfortable.

As I started my physical exam, it was clear that they were right. His mucous membrane color was pale pink, his heart sounded muffled, and his pulses were poor. Something was causing low cardiac output, and difficulty breathing. That something was also causing me great difficulty in hearing heart sounds.

Ultrasound confirmed pericardial effusion. The heart is actually contained in a fibrous sac, which has a small amount of fluid for lubrication and during the normal motion of the cardiac cycle. This space had become over-full with fluid, therefore exceeding the normal pressures of the heart, and causing it to collapse.

We quickly prepped his chest for removal of the fluid, which I would perform by inserting a needle with catheter into this space. The procedure went very well, and immediately Roscoe felt relief.

Unfortunately, as I re-ultrasounded his heart, the reason for the effusion became very clear. Roscoe had a very gnarly looking mass on his right atrium; most likely a hemangiosarcoma. This is a tumor of blood vessels, and the space was likely to fill up again, quickly, with fluid.

His family visited, considered their options, and ultimately, elected to euthanize Roscoe while he was in relative comfort. A very sad, difficult decision for them, but they could at least take comfort in knowing his diagnosis. Death of our pets is always an awful time, but some little part of me feels just a bit better when I know, beyond a doubt, that they have a terminal disease and that there was no chance for a cure. At least we really are preventing the invetable suffering. I really do believe that dogs and cats don't understand length of life, only quality of life.

Onwards.

The next case to walk through the doors was an very sick labrador. He was unable to walk, had collapsed that morning, and was brought in on a stretcher. His clients, who were not wearing shoes, noted that he had been the picture of health only a day before.

His physical exam was a classic ER presentation; white gums, elevated heart rate, poor pulses, and a distended, fluid filled abdomen. He was bleeding into his belly, probably from a bleeding mass. Most likely, this mass was cancerous. Ultrasound and abdominocentesis confirmed my presumptions. The only way to know, definitively, would be to stabilize and proceed with exploratory surgery. Unfortunately, he was euthanized as the clients could not afford, and furthermore, did not want to put their dog through surgery with the above knowledge. I made them a clay impression of each paw, and expressed my extreme sadness for their loss.

Sunday, June 5, 2011

My best save of the week was a 10 year old, female calico kitty. She presented in severe respiratory distress, with purple mucous membranes, gasping for air, and minutes from death. Her heart at triage was 100 beats per minute -- far to low for a cat, and as I listened, the rate was dropping dramatically. She was dying, NOW. Auscultation of her chest and her respiratory pattern were classic for pleural effusion, or fluid around the lungs. Fluid filling up in this space results in inability of the lungs to expand, and decreased area for gas exchange. When severe, as in this kitty, pleural effusion is essentially like drowning in the body's own fluid.

We provided her flow by oxygen and I shaved hair on the side of her chest. I inserted a butterfly needle into her chest and began to remove slightly white, milky fluid from her pleural space. 150ml was removed, a VERY large amount for a cat of her size (about 6#). She immediately began to breathe easier. We placed her in oxygen to let her rest, and moved on to the next case. A radiograph revealed that more fluid remained, however she was stabilized and would have to wait until the next critical patient was stable for further testing.

The next patient who had just arrived was a 15 pound beagle mix who had just been hit by a car. Her family immediately authorized any care necessary to improve her condition. An IV catheter was placed, and a fluid bolus initiated to improve her low blood pressure. Hydromorphone, a morphine derivative, was given for pain. "Suzie" was excruciatingly painful over her pelvis.

Radiographs were taken, and revealed 5 fractures in Suzie's pelvis, as well as a dislocated hip. Ultrasound and chest radiographs were clear, with no other injuries present. Her blood pressure had improved. I updated the family to the good news, and although Suzie would require surgery to repair her pelvis, she would likely survive. They were ecstatic, and hugged me and Suzie, as they left her for the evening.

Several outpatients later, I returned my attention to the kitty. Ultrasound of her chest revealed a moderate amount of fluid remaining, and I removed an additional 120ml. Chest radiographs and ultrasound revealed an enlarged heart, but Suzie was now breathing comfortably without oxygen, eating, grooming, and purring when we pet her. I saved her life, and she narrowly escaped death - a good feeling.

Suzie transferred to a surgical facility, where she did very well and went home 48 hours later. Her family called me a week later to thank me for saving their dog, for making a stressful evening a little easier, and for being compassionate.

These two cases felt really, really good. Like my header above says, it's not always this happy, as you've seen on my previous blogs, but I really love having the opportunity, knowledge, and ability to intervene and save furry, innocent lives.

The last several days at work have been jam-packed with the best of the ER. I've been too busy at work to blog, and too tired when home to write - I'll spend the next few days catching up on the action.

The first two cases I've grouped because they have a similar theme: B is for bones.

Tina, a 4 year old pit mix, presented to us early Monday with a primary complaint of "painful." Tina's owner, Sally, was a 30-something, friendly, level headed person. Upon arrival she noted that an acquaintance had given Tina rib bones, despite multiple pleas NOT to feed this to her dog. This, unfortunately, had happened before, and I had been the veterinarian to see her, so Sally was relieved to see me, a familiar face.

Tina had been vomiting bones, and was straining to defecate. She was painful. Physical exam revealed a fairly stable patient, with normal vital signs. Rectal exam, however was very abnormal. Shards of bone were present in the colon, easily within reach Tina had been straining to pass these splinters and fragments of bone, but the pain was too great for her. We administered a strong pain medication and sedative, and I removed these bones. Tina was 100% more comfortable, and radiographs revealed that no further bones remained. I sent her home with a zip-lock bag full of the bones I removed, and a letter to her friend, written in a professional tone, but with the gist being: STOP FEEDING BONES TO YOUR FRIEND'S DOG!

Chet, a 5 year old Cairn terrier, presented for abdominal pain. He was previously healthy, and had developed vomiting over the last 24 hours. His owner, David, revealed that his aunt had given Chet a knuckle bone 2 days ago.

Radiographs revealed bone shards throughout the intestinal tract, from the stomach all the way to the colon. Medical therapy was started, including IV fluids and pain control. Less than an hour after presentation, ultrasound revealed a perforation and immediate exploratory surgery was performed.

Exploratory surgery revealed a perforation at the distal ileum due to sharp fragments of bone. Surgery was difficult, and the bone was removed and the perforation repaired. Broad spectrum antibiotics, nutritional support, fluid therapy, and pain control were adjusted as needed over 3 days.

Chet discharged several days ago and is doing well. Needless to say, neither of these families will EVER feed bones to their dog(s) again!

All stories contained within this blog are inspired by my life as an emergency veterinarian. Details including but not limited to name, time of visit, species, and age are changed to protect the innocent and crazy alike. Any relationship to persons or animals, living or dead, is purely coincidental.

This isn't web DVM....

These stories are shared to inspire and to entertain. They are not intended to be medical advice. If your pet is sick, the only rational thing to do is have him or her seen (in real life) by a veterinarian.

Who is that masked woman, anyway?

Ever since I was little, I always had the dream of becoming a veterinarian. The dream has been realized, and my passion is emergency medicine. ER work has many pitfalls and disadvantages, but for me, the ability to be there in a moment of crisis and help both a beloved pet and their loving family, is worth the bad days.

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Definitions and commonly seen conditions

Anemia: Low PCV (see below). Anemia can result from external hemorrhage, internal hemorrhage, destruction of blood cells in the body, or inability to make new blood cells in the bone marrow.

Azotemia: Elevation in the BUN (blood urea nitrogen) or creatinine. BUN and creatinine are body wastes typically eliminated by the kidneys; increased levels in the body indicate kidney dysfunction, obstruction of urine, or severe dehydration.

Congestive Heart Failure (CHF): Accumulation of fluid in the lungs due to failure of the heart. Some symptoms include shortness of breath, decreased appetite, rapid breathing rates, coughing, and weakness.

Feline Lower Urinary Tract disease (also called feline idiopathic cystitis): A condition resulting in frequent, painful urination, and in the most severe cases, obstruction of the urethra. FLUTD has several potential causes and is also an extreme emergency.

GDV: Gastric dilatation and volvulus. Occurs in large breed dogs; the stomach fills with gas and twists. An extreme emergency, this condition is treated with stabilization and immediate surgery.

PCV: Packed cell volume. The percentage of red blood cells contained within a given sample of whole blood. Normal for dogs and cats is typically 35%-45%.